DREXEL UNIVERSITY COLLEGE OF MEDICINE

COMMON SYMPTOMS: A GRID OF DIFFERENTIAL DIAGNOSIS FOR REVIEW Rev. December 2018

Generally, for each diagnosis there appear first attributes of the symptom, then associated symptoms, then risk factors, then physical findings (in italics). This is a work-in-progress: more symptoms will be added in due course. The order of listing is Cardio-Pulmonary, GI, HEENT, Musculo-skeletal, general.

BEWARE: This table represents obvious simplification and selection. Of course, few patients will show all the findings for a given diagnosis, and in turn few findings are entirely specific to one diagnosis!

Particularly common causes are in blue. Wherever possible, the listed attributes are supported by evidence obtained by publications since 1990. An asterisk (*) indicates that such literature is available for the complaint or at least some disorders causing the complaint. Otherwise, the listings reflect consensus or traditional teachings. The most indicative findings are in bold.

Prepared by Steven J. Peitzman, MD, FACP symptom-table-rev-12-2018 December, 2018

SYMPTOM DIAG. 1 DIAG 2 DIAG 3 DIAG4 OTHER DXs CHEST PAIN Ischemic Heart Ischemic Heart NON-Ischemic Pericarditis Dissecting Aortic Disease:Angina* *Disease:Acute MI Causes [see also to Aneurysm Exertional Central in chest the right]* Pleuritic Felt as pressure, Radiation to arm(s), Not exertional Central in Acute Onset weight, discomfort jaw Described as sharp chest Severe Relieved by rest <6 Duration>30 or stabbing Radiates to arms, “tearing” quality minutes minutes Related to position jaw Pulse deficits Central in chest Assoc: sweating, Age < 40 Fever Focal neuro finding Radiation to nausea Assoc. with Rub arm(s), jaw Same risk factors as dizziness, flushing (Most are Male, D.M, smoker, angina (Note: includes idiopathic/viral, but high lipids Physical findings of anxiety-induced can be assoc. with Corneal Arcus CHF (minority) chest pain, common cancer, autoimmune Ear-lobe crease and sometimes disease) Carotid bruit assoc. with hyperventilation) Chest Pain Other

(Con’t) esophageal-based (GERD, spasm) Chest wall Inflammation Palpitations/ ANXIETY Hyperthyroidism* Panic Attack Dysrhythmia *(esp Other Causes: PACs or PVCs, Racing Heart Triggers (situations) Sweats Discreet episodes episodic A. Fib., Anemia Other somatic Heat intolerance Sweats Parox. Adrenergic drugs complaints Nervousness Shortness of Supraventricular Tachycardia) Otherwise normal Enlarged thyroid breath/choked

exam Tremor of hands feeling Sudden Other indicators of Hyperactive DTRs Shakiness onset/cessation stress or anxiety (note: fewer signs (these are DSM Sense of “flip-flop” and symptoms in criteria) or irregularity older age) Awareness in bed Heart rate >90 Syncope or near- bpm except in >60- syncope y-o Sense of pounding in neck (for PST) HR > 150 (ie, more than most sinus tach) A waves in neck veins COUGH, Post-URI Airway Asthma POST-NASAL GERD COPD*: smoking PERSISTENT Hyper-reactivity DRIP history; dyspnea on (> 3 WEEKS), Shortness of breath (also called Upper Heartburn, acid exertion; wheezing; History of acute Chest “tightness” Airway Associated taste in mouth diffusely decreased in otherwise URI [But other sx may Cough) [BUT, many or breath sound well-seeming be absent in cough- most patients lack intensity; early adult (note: May go on for >4 variant asthma] Patient aware of GI symptoms.] inspiratory crackles weeks! FH of asthma, post-nasal drip Response to anti- mutifactorial allergy, or eczema Chronic rhinitis GERD Rx Also: causation is Sometimes Wheezing Response to nasal ? Hoarseness in common) wheezing steroid some Eosinophilic bronchitis ACE inhibitor Sarcoidosis Lung Cancer Tb Bronchiectasis

SHORTNESS Asthma COPD CHF Anemia Pneumothorax Pneumonia OF BREATH Episodic Exertional Exertional Bleeding often GI Pericardial disease Coughing Coughing Positional(orthopnea) Headache Angina “Tight” feeling Cigarets Past MI Fatigue Anxiety Allergy, eczema Wheezing Hypertension Pallor (conjunctival Pleural fluid Wheezes Quiet breath Edema rim, nails) Pulm. Embolus sounds Crackles Early insp. crackles NVD S3

ABDOMINAL Appendicitis* Cholecystitis* Pancreatitis Diverticulitis Ruptured Ectopic PAIN, ACUTE RLQ RUQ or epigastric Epigastric LLQ Lower quadrant Migration of pain location Felt in back Fever Tenderness and Pain before Vomiting Fever History of rebound vomiting Pain radiation to Vomiting constipation Collapse Local tenderness shoulder Alcohol Local tenderness & Vaginal bleeding Guarding, rebound RUQ tenderness Abdominal rebound Missed period Fever Murphy Sign tenderness and Rebound

ABDOMINAL (5) (6) PID (7) Perforated (8)Kidney Stone PAIN, ACUTE OBSTRUCTION* Stomach/Intestine (con’t) Lower quadrant Typically begins in Crampy pain pain Generalized pain flank Vomiting Discharge Shocky Patient wants to Absence of b.m. Unprotected sex Hx of ulcer, move around Past surgery Local peritoneal NSAIDs, Radiation to Hyperactive, high- signs Guarding, Rebound genitals pitched bowel Tender Cervix Urgency/frequency sounds early, ileus Hematuria later Sometimes vomiting Distention Lack of local Hyper-resonance findings on abdo exam; sometimes CVA tednerness ABDOMINAL Irritable bowel Gall Bladder GERD ULCER “Non-specific” PAIN, syndrome* Disease* Pancreatitis RECURRENT “heartburn” Epigastric Recurrent “Crampy” pain RUQ or epigastric Worse supine Periods of pain obstruction Relieved by bowel location Worse with separated by movement Vomiting caffeine, “acid” months Diarrhea and/or Pain radiation to foods, chocolate Melena constipation shoulder Relieved by Alcohol Sense of being RUQ tenderness antacid Smoking “bloated” PE usually egative

VOMITING, Gastroenteritis Bowel Obstruction Diseases of Major Drugs (selected) Labyrinthitis/ ACUTE and especially Abdominal Organs Meniere’s (almost always ingestion of pre- Pain, not highly Anti-neoplastic associated with formed toxin (see localized Pancreatitis Many antibiotics Vertigo “diarrhea”) History past surgery Hepatitis Digoxin Nystagmus nausea) Abdo. Distention Cholecystitis Colchicine and tympani (usually associated Opiates High-pitched bowel with pain) NSAIDs (not sounds then ileus common)

VOMITING, Gastroenteritis Hepatitis esp A Early Pregnancy Medications (see Other Causes above) (selected) REPEATED Associated with Contaminated food Opportunity without Pain as diarrhea eg shellfish Missed menses and Self-induced Major Pre-formed toxin as Jaundice but may be Other signs of Binge drinking Symptom (ie with staph shows absent esp. early pregnancy Drug withdrawal not vomiting>diarrhea Tender liver (RUQ) Motion sickness Sometimes fever Dark urine Uremia pancreatitis, (viral or bacterial) Gastric outlet or acute bowel Foods to ask about: emptying defect (eg obstruction) eggs, pastry. diabetic gastroparesis) HEADACHE Migraine* Tension Meningitis* Brain Tumor Head Injury Intrancranial bleed Unilateral Generalized Fever Progressive (if chronic: Pulsating Absence of other Mental status Worse bending over subdural) Nausea findings change (esp. if + Neuro findings Cluster Headache Sens. to light or bacterial) Severe HBP noise Blunted mental Caffeine overuse or 4-72 hrs status withdrawl + Family Hx Resistance to Medication overuse flexion of neck headache (bacterial) DIZZINESS Benign Positional Labyrinthitis Hypovolemia and Stroke/TIA (rare Other Causes (Note: many (or “Positioning”) Postural as cause of Vertigo* Hypotension* dizziness alone) Meniere’s cases are multi- A single, extended Syndrome (triad of causal especially Fleeting vertigo and period, days to Feeling of Sudden onset episodic vertigo, in elderly sometimes nausea weeks faintness esp. on Other neuro tinnitus, hearing persons) with head Sometimes there standing symptoms loss) movements has been a Diarrhea, vomiting, Older age, risk Esp. turning over preceding viral blood loss factors for Psychosomatic/ in bed syndrome Increase in heart vasc.disease psychiatric nystagmus, nystagmus rate on Nystagmus of any provoked falls toward side of standing>30 bpm type Migraine presenting nystagmus (Dix- inner-ear lesion Drop in syst P >20 Other neuro signs: as vertigo Hallpike when walking mmHg eg, diplopia, speech maneuver) disorder, focal weakness

SORE Viral Streptococcal* Mononucleosis Gonococcal Peritonsillar abscess THROAT URI symptoms Fever Persistence Diphtheria NO cough Young adults Nodes Fatigue Exudate Rash Splenomegaly

KNEE PAIN, Septic Joint Gout Rheumatoid Pseudogout Arthrits (is usually Hemarthrosis in acute with Fever Extreme pain bilateral) patient on Swelling (non- IV drug use Past symptoms in Coumadin traumatic) Gonorrheal toe Morning stiffness Bursitis esp. pre- symptoms Metabolic Joint involvement patellar Fever, chills syndrome elsewhere, esp. Warm, red, swollen, On thiazide hands in PIP and tender Exquisite MPs: swelling, tenderness even to tenderness light touch (if classic) Warm, swollen Surrounding soft tissue swelling KNEE PAIN, Osteoarthritis Patello-Femoral Bursitis Rheumatoid Pain referred from Syndrome arthritis (see hip-joint disease subacute or Older age (“chondromalacia”) Pre-patellar: above) (clue: no findings at chronic Morning stiffness Repeated pressure all in knee) but < 30 minutes Age < 35 with on knee Pain felt medially exceptions (“washerwoman”); in knee Pain especially on redness & Past injury to knee going up or down tenderness over or leg (not needed) stairs lower patella. Non-warm Pain, crepitus, or Anserine: pain, Bony enlargement ‘grittiness’ with tenderness medially Crepitus with ROM pressure on patella 5-6 cm below joint Tenderness at against femur line medial joint line With both, joint not really involved so no loss of ROM LOW BACK Lumbo-Sacral Herniated Disc* Spinal Stenosis Spondylolysis/ Renal Colic (stone) “Strain” spondylithesis PAIN Sudden onset Older Age Severe Sudden onset Radicular Chronic pain, often Adolescent waxing/waning pain Otherwise well symptoms: into legs Follows sports Pt moves about Young or old “Sciatic” pain or “Psuedo- activity Refers to genitalia Improving within leg paraesthesia claudication”: pain Sometimes with Urinary few days + Straight-leg raise with standing or radiculopathy frequency/urgency No focal neuro. (+ means induces walking, relief Gross or findings leg pain) with sitting or microscopic Neuro finding L4 – bending forward hematuria S1 + CVA tenderness

SHOULDER Rotator Cuff Rotator Cuff Acromioclavicular Glenohumeral Referred: Tendinitis* Tear* Arthritis arthritis (rare!) PAIN (other than (Includes, ie, gall Pain sensed in traumatic) Pain felt at “point” Pain felt in outer bladder disease; deltoid area of shoulder, arm cervical spine Pain worsen with Pain felt in outer superiorly. ROM very limited, disease; myocardial abduction (esp. at arm Tenderness at A-C including passive ischemia) or above Over 60 years of joint horizontal, age Pain worsens with Suggested by “painful arc”). Positive “dropped full aDduction maintenance of full Impingement signs arm sign” ROM without may be positive Weakness and/or worsening pain, no pain with attempt to tenderness, suitable raise outstretched context such as arms against appropriate age for resistance (esp with angina or MI thumbs pointed down) ELBOW Lateral Medial Olecranon bursitis Actual arthritis of Not many other Epicondylitis Epicondylitis elbow joint causes! PAIN (“Tennis Elbow”) [causes: sustained pressure (eg elbow [causes: RA, Pain in lateral Pain in medial resting on desk psoriatic; note: elbow area, elbow area long time); gout; osteoarthtitis sometimes also infection; RA; RARE in elbow!] wrist Pain worsens with hemorrhage] Pain worsens with resisted Pain, tenderness, resisted plantarflexion of Exam shows: almost always dorsiflexion of wrist limitation of wrist Local tenderness Cystic swelling over ROM—pt cannot Local tenderness over Medial olecranon straighten arm if over lateral epicondyle May be red, warm there is true epicondyle ROM at elbow disease in elbow maintained joint (as opposed to olecranon bursa or tendon insertions)!

FATIGUE Depression Sleep Apnea Chronic Fatigue Hypothyroidism* Other Causes (prolonged) Syndrome Low mood Daytime Cold intolerance Medications (esp. Lack of interest drowsiness Muscle/joint aches Constipation anti-depressants) Early awakening Snoring Headaches Hoarseness Anemia Slowness, lack of Obesity Tender nodes Bradycardia Heart Failure affect M>F; Dry, coarse skin Lung failure Older>younger Slowed ankle jerk Uremia (CKD) Malignancy Chronic infection (eg TB, HIV)

DIARRHEA, VIRAL (Norwalk, Pre-Formed Toxin Bacterial, Drug-Induced Other Causes norovirus, others) inflammatory ACUTE Rapid onset (<6 Laxatives Anxiety (resource-rich Most common hours) Fever Some antibiotics Hyperthyroidism regions) Watery Staph: custards, May be bloody Caffeine Protozoa Vomiting may also meats, dairy; Salmonella (eggs, Alcohol Giardia Many anti-cancer be present outbreaks poultry, almost drugs No fever or mild Vomiting usually anything); Camp. Lactulose (used for Benign abdominal predominates Jejuni (poultry, liver failure; osmotic exam No fever pets); Shigella agent (fecal-oral); e. coli Colchicine (for gout) B. Cereus: the 0157-H7 Proton Pump In same, from rice, hibitors (rarely) meat And many others; above list is of some common examples DIARHEA, Certain infections: Inflammatory Irritable bowel Malabsorption Other Causes eg, giardia, ameba, Bowel Disease disorder (eg pancreatic (there are many!) Chronic (> 4 cryptosporidium) (Ulcerative colitis, insufficiency, weeks) or Crohn’s) Abdominal Pain lactase deficiency, Drugs (see list Recurrent Recent travel Diarrhea may celiac disease*) above; consider Abdominal pain Abdominal pain alternate with laxative overuse, Diarrhea Fat-containing Diarrhea is often constipation Large amount of which pts malodorous stools bloody “Bloating” stool sometimes do not (giardia) Systemic Mucus with stool Fat-containing easily reveal. Weight loss manifestations malodorous stools (joints, skin, fever) Diarrhea soon Hyperthyroidism after a meal Anxiety (*symptoms may be minimal and varied; considered to be underdiagnosed.) SYNCOPE* “Neurally Orthostatic Heart block or Aortic Stenosis NOTE: The (Syncope means a mediated” hypotension dysrhythmia following can sudden brief loss including Older age cause l.o.c. but not of consciousness “vasovagal,” faint Occurs upon Known heart History of sob usually defined as with spontaneous or swoon standing disease History of chest true syncope and complete Anti-hypertensive History of pain (because recovery recovery, that is, Long history of drugs palpitations esp. just is slow, residual person wakes up recurrence Occurs with before episode Systolic murmur findings, etc.) without neurologic Otherwise healthy standing after Can occur with pt deficit.) Note: with no known exertion supine (ie, would Seizure (witnessed episodes of “near- heart disease Occurs with speak against movement?) syncope” – After traumatic or bleeding, volume causes to the left) Blood loss (GI faintness but unpleasant event, contraction of any symptoms?) without full loss of sight, smell; severe cause Pulse irregularity Posterior circulation consciousness – pain and/or TIA or stroke (focal probably has very After prolonged Orthostatics show HR <50 or >100 neuro findings) similar differential. standing, esp. if hot, drop in BP, or Murmur Pulmonary crowded increase in heart embolism (risk Sometimes rate >30, or pt feels factors for DVT?) associated with dizzy on standing palor, nausea Post-meal (elderly)

ACUTE Deep vein Cellulitis Calf muscle “pull” Very inflamed Popliteal cyst thrombosis or tear knee joint SWELLING Redness and OF ONE Tender warmth > swelling Relevant history Focal tenderness, LOWER May be pitting Tender ecchymoses heat at knee joint Risk factors Fever History of gout LEG, usually include: recent Source eg: abrasion, (note: gout has painful immobility; recent cut, ulcer, bad tinea special tendency to surgery, trauma or pedis. induce surrounding serious illness; soft tissue swelling previous known DVT; cancer. EDEMA, CHF Cirrhosis Nephrotic Acute or Chronic Constrictive Dyspnea; Predominance of Syndrome Severe Renal pericarditis. BILATERAL orthopnea; known ascites; sharp liver Sudsy or frothy Disease (ie low GFR, Severe lung disease PITTING (ie heart disease or edge; jaundice; hx urine; tendency to inability to excrete salt Extreme protein generalized indicators of it on of alcoholism facial edema and water even if no malnutrition physical exam, ecg, (puffiness) nephrotic syndrome) edema) etc. See: CHF under shortness of breath Menstrual Fibroids Polyps Uterine Cancer Coagulation Bleeding, Pelvic pain, disorder (eg, Von pressure feeling. Often inter- Willebrand) heavy (note: menstrual bleeding falls under Urinary Usually otherwise Bleeding elsewhere frequency. without clear (eg, bruising, gums, Abnormal Enlarged uterus symptoms. mucosal if from low Uterine Risk factors: platelets or von Bleeding) obesity; use of Willebrand); tamoxifen. Family History Pts may have Chronic liver symptoms of disease anemia. A FEW Urinary Loss of Appetite: MORE frequency, (There are many urgency: causes. Here we SYMPTOMS, refer to more than BRIEFLY • UTI transient in duration) • Diabetes

• Prostatism • Cancer (BPH) • Uremia • Stones • Hepatitis and • Bladder other liver Cancer disorders • Psychosomatic • Medications • Pregnancy (eg chemo) • Depression • Chronic infections